Good Evaluations Guide Treatment: What Are We Doing Wrong?

Good Evalutations Guide Treatment

An 85-year-old woman walks into an outpatient swallowing clinic to get help for her difficulty swallowing. She comes out with a folder full of dietary suggestions, swallow strategies, tongue exercises, and swallowing exercises.

She faithfully performs her exercise drills every morning and evening, laughing at herself making faces in the mirror. She tries to hold her tongue out while she effortfully swallows saliva (Masako Tongue-Hold), but this is hard because her mouth is so dry. She wonders how these exercises are going to help her swallow better.

During meals, she tucks her chin and effortfully swallows two times after every bite of food. However, she still is bothered by that lump-in-the-throat sensation and the feeling of food stuck. Liquid comes back up when she tries to wash foods down, and she can only eat a small amount before the food feels like it is coming back up into her throat. Most concerning to her, she is still losing weight. She wonders: “What am I doing wrong?”

We need to ask ourselves, “What are we doing wrong?” First gather all the right information and start with an accurate diagnosis.1

What are we doing wrong?

This case is a perfect example of why the swallowing specialist needs a complete understanding of a patient’s swallowing physiology before prescribing swallowing maneuvers and exercises.

If we miss the underlying cause for the difficulty swallowing, “we treat a symptom and not its cause.”1 This point was stressed multiple times at this year’s Dysphagia Research Society 23rd Annual Meeting, March 12-14, 2015, Chicago, IL (#DRS2015). Dysphagia is not a disease in and of itself; dysphagia is a symptom of underlying problems across many systems. We, as deglutologists, need to find the underlying issues that cause the swallowing dysfunction.

Dysphagia requires a multidisciplinary approach. As stated by the 2014-2015 president of the Dysphagia Research Society, Dr. Kulwinder Dua, MD, “If there is no cross-talk (among the subspecialties), we are working in isolation and that is a disaster.” 600,000 people die every year due to complications from dysphagia, per Dr. Dua; more than from liver disease, kidney disease, and HIV combined, and similar to that of diabetes.

What can we do?

Dr. James Coyle1 shared this advice:

  1. Do not treat a symptom in isolation without knowing why.
  2. Do not treat the barium. In other words, do not treat the bolus.
  3. Ask: What did the patient do to make the barium/bolus aspirate?
  4. Then: leave the aspiration issue to manage a host of other risk factors. Pneumonia is multifactoral, and underlying causes of dysphagia are multifactoral.

As stated by Joan Arvedson, PhD, CCC-SLP, BCS-S, at the 2015 Dysphagia Research Society Meeting, we need to ask: “What else?” Part 2 of this article will address this important question by analyzing the components of thorough dysphagia evaluations: the examination and scope of practice.

  1. Coyle, J.L. (2014, April). IIS5: Dysphagia Interventions: Are We Treating the Bolus, the Patient, or Something Else? Seminar presented at the Healthcare & Business Institute of the American Speech-Language-Hearing Association, Las Vegas, NV.